Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 20 - FAMILY PLANNING - HAVING THE NUMBER OF CHILDREN YOU WANT

(introduction...)

Is Birth Control Good - and Is It Safe?

Choosing a Method of Birth Control

Birth Control Pills (Oral Contraceptives)

Other Methods of Birth Control

Combined Methods

Methods for Those Who Never Want to Have More Children

Home Methods for Preventing Pregnancy

(introduction...)

BOTH THESE FAMILIES LIVE IN POOR COMMUNITIES:

This family lives where wealth is
distributed unfairly.

This family lives where resources
are distributed fairly.

Some mothers and fathers want a lot of children - especially in
countries where poor people are denied a fair share of land, resources, and
social benefits. This is because children help with work and provide care for
their parents in old age. In such areas, having just a few children may be a
privilege only wealthier people can afford.

The situation is different in poor countries where resources and
benefits are fairly distributed. Where employment, housing, and health care are
guaranteed and where women have equal opportunities for education and jobs,
people usually choose to have smaller families. This is in part because they do
not need to depend on their children for economic security.

But in any society, it helps if a family has control over how
many children they have, and when they have them.

When a mother has child after child, without much space between,
she often becomes weak. Her babies are more likely to die. Also, after many
pregnancies the danger is greater that she will die in childbirth, leaving many
motherless children. Therefore many couples now choose to allow two or more
years to pass between pregnancies, and avoid having a very large number of
children.

If a man and woman have a lot of children, when the children
grow up there may not be enough land for all of them to grow the food their
families need. Children may begin to die of hunger. This is already happening in
many areas.

Although most, if not all, hunger in the world today could be
prevented if land and wealth were distributed fairly, the growing number of
people is part of the problem. But the solution is not to force the poor to
limit the number of children they have. Instead, the challenge is for societies
to provide enough security so that the poor can afford to have few children.

FAMILY PLANNING AND BIRTH CONTROL

Different parents have different reasons for wanting to limit
the size of their family. Some young parents may decide to delay having any
children until they have worked and saved enough so that they can afford to care
for them well. Some parents may decide that a small number of children is
enough, and they never want more. Others may want to space their children
several years apart, so that both the children and their mother will be
healthier. Some parents may feel they are too old to have more children.

Family planning is having the number of children you want,
when you want them.

When a man and woman decide when they want to have children, and
when they do not, they can choose one of several methods to prevent the woman
from becoming pregnant, for as long as she wishes. These are methods of birth
control or contraception.

Couples who want children but are not able to have them should
see section: Men and Women Who are Not Able to Have Children
(Infertility).

Is Birth Control Good - and Is It Safe?

1. Is it good?

In some parts of the world there has been a lot of discussion
about whether different forms of birth control are good or are safe. Some
religions have been against any form of birth control except trying not to have
sex together. But an increasing number of religious leaders are realizing how
important it is to the health and well-being of families and communities that
people be able to use easier and surer methods of birth control.

Also, in many places women who get pregnant when they do not
want a child will go for an abortion, to have the pregnancy removed.
Where these abortions are legal, they can be done in health centers under
sanitary conditions, and they are not usually dangerous to the woman. But where
abortions are not permitted, many women get abortions illegally and secretly,
often in dirty conditions and performed by unskilled persons. Thousands of women
die from such abortions. If women are given the chance to use birth control
methods, and information to use them wisely, many abortions, legal and illegal,
would not be necessary. Much needless suffering and death could be prevented.
(See Complications from Abortion)

Some people feel that much of the push for family planning comes
from rich countries or persons who want to keep their control over the poor by
controlling their numbers. The rich and powerful find it hard to accept that the
way they manage the earth's land and resources strongly contributes to world
hunger. They see only the growing numbers of people. In some countries
professionals sterilize poor women by force or experiment on them with new or
unsafe methods. For all these reasons social reformers and spokespersons for the
poor often protest against birth control.

This is unfortunate. The object of attack should not be birth
control, but rather its misuse. The attack should be against social injustice
and the unfair distribution of land and-wealth. If used well, birth control can
in fact help the poor gain strength to work for their basic human rights. But
the decisions and responsibility for family planning must be in the hands of the
people themselves.

Decide for yourself if and how you want to plan your
family. Do not let anyone else decide for you.

2. Is it safe?

Whether or not different forms of birth control are safe has
been much discussed. Often those who are against birth control for religious or
political reasons try to scare women by talking about the risks. Some methods do
have certain risks. However, the important thing all women should realize is
that birth control is safer than pregnancy, especially for women less
than 20 or more than 35 years old, and for women who have had many children.

The risk of serious illness or death resulting from pregnancy
is many times greater than the risks involved in using any of the common methods
of birth control.

There is much talk about the risks of taking birth control
pills. But the risks with pregnancy are many times greater. The pill works so
well in preventing pregnancy that for most women it is safer - in terms of
protecting their lives - than any of the other 'less risky' but less effective
methods.

Choosing a Method of Birth Control

On the following pages several methods of birth control are
described. Some work better for some people than others. Study these pages, and
talk with your midwife, health worker, or doctor about what methods are
available and are likely to work best for you. Differences in effectiveness,
safety, convenience, availability, and cost should be considered.
Husbands and wives should decide together, and share the responsibility.

AVERAGE EFFECTIVENESS OF DIFFERENT
FORMS OF BIRTH CONTROL

* With sterilization, problems occasionally result
from surgery but the method is
permanent.

Birth Control Pills (Oral Contraceptives)

Birth control pills are made of chemicals (hormones) that
normally occur in a woman's body. When taken correctly, the 'pill' is one of the
most effective methods for avoiding pregnancy. However, certain women should not
take birth control pills if they can use another method. Birth control pills do
not prevent AIDS or any other sexually transmitted diseases. To prevent these
diseases, use a condom. If possible, birth control pills should be given by
health workers, midwives, or other persons trained in their use.

The pills usually come in packets of 21 or 28 tablets. The
packets of 21 are often less expensive, and of these, some brands are cheaper
than others. The amount of medicine differs in different brands. To pick the
kind that is right for you, see the GREEN PAGES.

Figure

How to take the pills - packet of 21:

Take the first pill on the fifth day from the beginning of your
period, counting the first day of the period as day 1. Then take 1 pill every
day until the packet is finished (21 days). Take your pills at the same time
each day.

After finishing the packet, wait 7 days before taking any more
pills. Then begin another packet, 1 pill each day.

This way, you will take the pills for 3 weeks out of each month,
then go 1 week without taking any. Normally, the menstrual period will come
during the week when the pill is not taken. Even if the period does not come,
start the new packet 7 days after finishing the last one.

If you do not want to get pregnant, it is important to take
the pills as directed - 1 every day. If you forget to take the pill one day,
take it as soon as you realize this, or take 2 the next day.

Packet of 28 pills:

Take the first pill on the fifth day of the period, just as with
the packets of 21. Take 1 a day. Seven of the pills will probably be a different
size and color. Take these pills last (one a day) after the others have all been
taken. The day after you finish the packet of 28, start another packet. Take 1 a
day without ever missing a day, packet after packet, for as long as you want not
to get pregnant.

No special diet must be followed when taking the pill. Even if
you happen to get sick with a cold or another common illness while taking birth
control pills, go right on taking them. If you stop taking the pills before the
packet is used up, you may become pregnant.

Side effects:

Some women get a little morning sickness, swelling of the
breasts, or other signs of pregnancy when they first start taking the pill. This
is because the pill contains the same chemicals (hormones) that a woman's body
puts into her blood when she is pregnant. These signs do not mean she is
unhealthy or should stop taking the pill. They usually go away after the first 2
or 3 months. If the signs do not go away, she may need to change to a kind with
a different amount of hormone. This is discussed in the GREEN PAGES.

Most women bleed less than usual in their monthly period when
they are taking the pill. This change is usually not important.

Is it dangerous to take oral contraceptives?

Like all medicines, birth control pills occasionally cause
serious problems in certain persons. The most serious problems related to the
pill are blood clots in the heart, lungs, or brain (see stroke). This occurs
most often in women who smoke - especially if they are over 35. However, the
chance of getting dangerous clots is higher when women get pregnant than when
they take the pill.

Although it is rare, a woman may become pregnant while taking
the pill. If this happens, immediately stop taking the pill because it
can harm the developing baby.

Death related to taking the pill is rare. On the average,
pregnancy and childbirth are 50 times as dangerous as taking the pill.

Of 15,000 women who become pregnant, this many are likely to die
from problems of pregnancy or childbirth.

Figure

Of 15,000 women who take birth control pills, only 1 is likely
to die from problems related to having taken the pills.

Figure

Conclusion:IT IS MUCH SAFER TO TAKE THE PILL THAN TO BECOME
PREGNANT.

For most women, birth control pills are relatively safe.
Certainly they are far safer than becoming pregnant. However, for some women
both pregnancy and taking birth control pills have a higher risk. These women
should use other methods of birth control.

Who Should Not Take Birth Control Pills?

A woman who has any of the following signs should not take oral
(or injected) contraceptives:

· A woman, whose
period is late, who thinks she might be pregnant.

·Deep or steady pain in one
leg or hip. This may be caused by an inflamed vein (phlebitis or blood
clot). Do not use birth control pills. (Women with varicose veins that
are not inflamed can usually take birth control pills without problems. But they
should stop taking them if the veins become inflamed.)

Figure

·Stroke. A woman who has
had any signs of a stroke should not take the pill.

Figure

·Hepatitis, cirrhosis, or
other liver disease. Women with these problems, or whose eyes had a yellow
color during pregnancy, should not take the pill. It is better not to take oral
contraceptives for one year after having hepatitis.

Figure

·Cancer. If you have had
or suspect cancer of the breast or womb, do not use oral contraceptives. Before
beginning oral contraceptives, examine your breasts carefully. In some health
centers you may also be able to get a simple test (Pap smear) to check for
cancer of thecervix or opening of the womb. Birth control pills
have not been proven to cause cancer of the breasts or womb. But if cancer
already exists, the pill can make it worse.

Figure

Some health problems maybe made worse by oral contraceptives. If
you have any of the following problems, it is better to use another method if
you can:

·Migraine.
Women who suffer from true migraine should not take oral contraceptives. But
simple headache that goes away with aspirin is no reason not to take the pill.

·Urinary infection with
swelling of the feet.

·Heart disease.

· High blood
pressure.

If you suffer from asthma, tuberculosis, diabetes or epilepsy,
it is best to get medical advice before taking birth control pills. However,
most women with these diseases can take oral contraceptives without harm.

Precautions Women Should Take when Using Birth Control
Pills

1. Do not smoke, especially if you
are over 35. It can cause heart problems.

2. Examine the breasts carefully
every month for lumps or possible signs of cancer.

3. If possible, have your blood
pressure measured every 6 months.

4. Watch for any of the problems mentioned in section
Who Should Not Take Birth Control Pills?, especially:

· Severe and
frequent migraine headaches.

· Dizziness, headache, or loss
of consciousness that results in difficulty in seeing, speaking, or moving part
of the face or body (see Stroke).

· Pain with inflammation in a
leg or hip (chance of a blood clot).

· Severe or repeated pain in the
chest (see Heart Problems).

If one of these problems develops, stop taking the pill and get
medical advice. Avoid pregnancy by using another method, as these problems also
make pregnancy especially dangerous.

Questions and Answers about Birth Control Pills

Some people claim birth control pills cause cancer. Is this
true?

No! However, if cancer of the breast or womb already exists,
taking the pill may make the tumor grow faster.

Can a woman have children again if she stops taking the pill?

Yes. (Sometimes there is a delay of 1 or 2 months before she
can become pregnant.)

Is the chance of having twins or defective children greater if a
woman has used oral contraceptives?

No. The chances are the same as for women who have not taken
the pill.

Is it true that a mother's women breasts will dry up if she
starts taking birth control pills?

Some women will produce less milk when taking the pill. So it
is best to use another method of birth control while nursing, and later change
to the pill. Or she can take the 'mini-pill', which contains so little hormone
that it usually does not affect the milk.

Other Methods of Birth Control

THE CONDOM (also called 'prophylactic', 'rubber', or
'sheath') is a narrow rubber or latex bag that the man wears on his penis while
having sex. Usually it works well to prevent pregnancy. It is also the only
effective method for preventing AIDS, and other sexually transmitted
diseases, but is not a complete safeguard.

Figure

Put on the condom while the penis is stiff, and leave space at
the tip for sperm. The man should hold on to the condom when he pulls out his
penis.

You can buy condoms in most pharmacies. Some are cheaper than
others. Condoms are sometimes given away free at health clinics or family
planning clinics. It is best to use a condom only once. (However, a washed and
re-used condom, although not as safe, may be better than none. Fill with water
to check for leaks.)

THE DIAPHRAGM is a shallow cup made of soft rubber, A
woman wears it in her vagina while having sexual relations. It should be left in
for at least 6 hours afterward. It is a fairly sure method if used together with
a contraceptive cream or jelly. A health worker or midwife should help fit the
diaphragm, as different women need different sizes. Check the diaphragm
regularly for holes and cracks by holding it up to the light. If there is even a
tiny hole, get a new one. They usually last a year or longer. After use, wash it
in warm soapy water, rinse, and dry. Keep in a clean, dry place.

Figure

CONTRACEPTIVE FOAM comes in a tube or can. The woman puts
it into her vagina with a special applicator. It must be applied no longer than
1 hour before having sex, and left in for at least 6 hours afterward. The
application should be repeated before each time the couple has sex, even if this
is several times in one night. It is a fairly sure method if used correctly.

Figure

THE INTRAUTERINE DEVICE (IUD) is a plastic (or sometimes
metal) object that a specially trained health worker or midwife places inside
the womb. While in the womb, it prevents pregnancy. IUDs fall out of some women.
In others they cause pain, discomfort, heavy bleeding during periods, and
sometimes serious problems, but for some women they give no trouble, at all. For
these women, the IUD may be the simplest and most economical method.

Figure

WITHDRAWAL OR PULLING OUT (COITUS INTERRUPTUS) is a
method in which the man pulls his penis out of the woman before the sperm comes.
This method is perhaps better than none, but may be disturbing to the couple and
does not always work, because some men do not pull out in time, especially if
they have been drinking.

THE RHYTHM METHOD

This method is not very sure to prevent pregnancy, but it has
the advantage of not costing anything. It is more likely to work for a woman
whose periods come very regularly, more or less once every 28 days. Also,
the husband and wife must be willing to pass one week out of each month without
having sex the regular way.

Usually a woman has a chance of becoming pregnant only during 8
days of her monthly cycle - her 'fertile days'. These 8 days come midway between
her periods, beginning 10 days after the first day of menstrual bleeding. To
avoid getting pregnant, a woman should not have sex with her man during these 8
days. During the rest of the month, she is not likely to get pregnant.

To avoid confusion the woman should mark on a calendar the 8
days she is not to have sex.

For example: Suppose your period
begins on the 5th day of May. Count that as day number 1.

During these 8 'fertile days', do
not have sexual relations.

If the woman and her husband carefully avoid having sex together
during these 8 days of each month, it is possible that they will go years
without having another child. However, few couples are successful for very long.
This is not a very sure method, unless used in combination with another method
such as a diaphragm or condoms, especially during the days from the end of the
menstrual period until the fertile days are over.

THE MUCUS METHOD

This is a variation of the rhythm method. A woman finds out when
she could become pregnant by checking the mucus in her vagina every day. It
works fairly well for some couples but not for others. In general it cannot be
considered a very sure way of preventing pregnancy, but' it costs nothing and
has no risks other than those that come with pregnancy itself. However, it is
more difficult to do if the woman has a vaginal infection with a lot of
discharge, if her periods are not regular, or if she douches often.

Every day, except during her period, the woman should examine
the mucus from her vagina. Take a little mucus out of your vagina with a clean
finger and try to make it stretch between your thumb and forefinger, like this:

As long as the mucus is sticky like paste - not slippery or
slimy - you probably cannot become pregnant, and can continue to have sexual
relations.

Figure

When the mucus begins to get slippery or slimy, like raw egg, or
if it stretches between your fingers, you may become pregnant if you have sexual
relations. So, do not have sex when the mucus is slippery or stretches, or
until 4 days after it has stopped being slippery or stretchy and has become
sticky again.

Figure

The mucus will usually become slippery during a few days midway
between your periods. These are the same days you would not have sex with your
man if you were using the rhythm method.

To be more sure, use the mucus and rhythm methods together. To
be still more sure, see
below.

Combined Methods

If you want to be more certain not to become pregnant, it often
helps to use 2 methods at the same time. The rhythm or mucus method combined
with the use of a condom, diaphragm, foam, or sponge is surer than any of these
methods alone. Likewise, if a man uses condoms and the woman a diaphragm or
foam, the chance of pregnancy is very low.

INJECTIONS. There are special injections to prevent
pregnancy.Depo-Provera is one. An injection is usually given
every 3 months. Side effects and precautions are similar to those for birth
control pills: After a woman stops getting injections, it can take a year or
more for her to become pregnant. But to avoid pregnancy, it is wise to use
another form of birth control.

Figure

IMPLANTS. With this method, 6 small tubes are put under
the skin. If left there, they can prevent pregnancy for up to 5 years. Menstrual
bleeding may be heavy during the first year. Return to the clinic if this
happens.

Figure

Injections and implants are useful for women who have trouble
remembering to take pills, or who run into problems using other kinds of birth
control.

Methods for Those Who Never Want to Have More Children

STERILIZATION. For those who never want to have more
children, there are fairly safe, simple operations for both men and women. In
many countries these operations are free. Ask at the health center.

·For men,
the operation is called a vasectomy. It can be done simply and quickly in a
doctor's office or a health center, usually without putting the man to sleep.
Small cuts are made here so (1) that the tubes from the man's testicles can be
cut and tied. The testicles are not removed.

Figure

The operation has no effect on the man's sexual ability or
pleasure. His fluid comes just the same, but has no sperm in it.

·For women, the
operation is called a tubal ligation, which means to tie the tubes. One method
is to make a small cut in the lower (2) belly so that the tubes coming from the
ovaries, or egg-makers, can be cut and tied. It can usually be done in a
doctor's office or health center without putting the woman to sleep. Although
usually successful, there is a higher risk of infection in the operation for
women than for men.

Figure

This operation has no effect on the woman's menstrual periods or
sexual ability, and may make having sex more pleasant because she does not have
to worry about
pregnancy.

Home Methods for Preventing Pregnancy

Every land has 'home remedies' for preventing or interrupting
pregnancy. Unfortunately, most either do not work or are dangerous,. For
example, some women think that to wash out the vagina or to urinate after having
sex will prevent pregnancy, but this is not true.

BREAST FEEDING. While a woman is breast feeding her baby
she is less likely to become pregnant - especially when breast milk is the only
food her baby receives. The chance of her becoming pregnant is much greater
after 4 to 6 months, when the baby begins to get other foods in addition to
breast milk. Even then, breast feeding can help prevent pregnancy if she breast
feeds frequently, both day and night, and gives breast milk as the main food.
(But if her periods start, she cannot depend on breast feeding to prevent
pregnancy.)

Figure

To be more sure she will not become pregnant, the mother who is
breast feeding should begin some method of birth control when the baby is 3 to 4
months old. A method other than birth control pills is better because the pills
cause some women to produce less milk. (The 'mini-pill' causes less of a
problem.)

THE SPONGE METHOD. Here is a home method that is not
harmful and sometimes works. You cannot be sure it will prevent pregnancy every
time, but it can be used when no other method is available.

You will need a sponge and either vinegar, lemons, or
salt. Either a sea sponge or an artificial sponge will work. If you do
not have a sponge, try a ball of cotton, wild kapok, or soft cloth.

Figure

· Mix:

2 tablespoons vinegar in 1 cup clean
water

or

1 teaspoon lemon juice in 1 cup clean
water

or

1 spoon of salt in 4 spoons clean water

Figure

· Wet the sponge with one of
these liquids.

· Push the wet sponge deep into
your vagina before having sex. You can put it in up to an hour before.

· Leave the sponge in at least 6
hours after having sex. Then take it out. If you have trouble getting it out,
next time tie a ribbon or piece of string to it that you can pull.

Figure

The sponge can be washed and used again, many times. Keep it in
a clean place.